Zusammenfassung
Patienten mit diffus erkrankten, kleinen Coronarien, schweren Verkalkungen in der Aorta ascendens oder nicht vorhandenem bzw. unbrauchbarem venösem Bypassmaterial haben wir gezielt aus dem Kollektiv der über 70-jährigen Bypasspatienten ausgewählt und unter Verwendung beider Brustwandarterien in T-graft-Technik operiert.
Im retrospektiven Vergleich der beiden Patientengruppen, die wir entweder konventionell (Arterie±Vene/n; n=366) oder unter Verwendung der rechten und linken A. thoracica (±Vene/n; n=128) operiert haben, zeigten sich teilweise signifikante Unterschiede bezüglich des präoperativen Risikoprofils und der postoperativen Komplikationsraten.
In der T-graft-Gruppe waren mehr adipöse Patienten (BMI>30), während in die konventionell operierte Gruppe vermehrt Patienten mit schlechter Ventrikelfunktion und Notfallpatienten eingeschlossen wurden.
Postoperativ fand sich in der T-graft-Gruppe eine signifikant höhere Komplikationsrate bezüglich neurologischer Ereignisse, auch die Langzeitverläufe mit Langzeitbeatmung und Tracheotomie waren dementsprechend in dieser Gruppe höher, als in der Gruppe der konventionell Operierten. Die 30-Tages-Letalität unterschied sich prozentual (3,9 vs. 2,4%) ohne signifikante Relevanz.
Kein Todesfall in der T-graft-Gruppe war auf eine Bypassdysfunktion zurückzuführen. Drei der T-graft-Patienten verstarben in Folge postoperativer Komplikationen (Revision wegen Blutung, Sternuminstabilität, Mediastinitis), die der extendierten Präparationstechnik und den größeren Wundflächen zugeschrieben werden können, zwei weitere verstarben auf Grund neurologischer Komplikationen bei vorbestehenden schweren Verkalkungen in der Aorta ascendens.
In der konventionell operierten Gruppe, in der vermehrt Patienten mit schlechter Ventrikelfunktion oder Notfallpatienten mit involving infarction zu finden waren, war bei über der Hälfte der Verstorbenen die Todesursache Folge ihrer präoperativ schlechten kardialen Situation.
Unsere Ergebnisse legen nahe, über 70-Jährige bevorzugt dann erweitert arteriell zu operieren, wenn die coronaren Zielgefäße klein und diffus erkrankt sind, um ein mismatch zwischen graft und Zielgefäß zu vermeiden. Weitere Indikationen sind fehlendes bzw. qualitativ schlechtes Venenmaterial oder wenn eine schwer verkalkte Aorta ascendens den Verzicht auf zusätzliche Ausklemmung für proximale Anastomosen indiziert.
Die extendierte Präparationstechnik allerdings kann, in Kombination mit der altersbedingt hohen Begleitmorbidität, vermehrt zu postoperativen Komplikationen führen, so dass wir zum jetzigen Zeitpunkt nicht den routinemäßigen Einsatz, sondern eine differenzierte Indikationsstellung für dieses Operationsverfahren bei alten Menschen favorisieren.
Abstract
Patients, having diffusely diseased coronary arteries, severe calcifications in the wall of the ascending aorta, non-available or insufficient venous bypass material, were selected from all patients more than 70 years suffering from coronary artery disease and were treated by using the left and right thoracic artery as bypass material (T-graft procedure).
Comparing group 1: conventional ACVB (1 artery ± venous grafts, n=366) and group 2: T-graft operations (LIMA+BIMA±vein/s; n=128) retrospectively, significant differences in preoperative risk-factors and postoperative complications were observed. The T-graft group included more patients having a BMI >30, whereas in the conventionally operated ACVB group there were more patients with poor ventricular functions and more emergency cases.
Postoperative there were more neurological events with prolonged ICU-stays and tracheotomies in the T-graft group. The 30-day lethality was different in both groups (3.9 vs 2.4%) but without significant relevance.
In the T-graft group no cause of death was due to bypass dysfunction. Three patients died from a chain of postoperative complications (revision due to bleeding, instability of the sternum, mediastinitis) that might be due to the extended preparation of the two thoracic arteries and therewith to the enhanced intraoperative trauma. Two patients died from neurological events most probably due to their severely calcified ascending aorta. In the conventional bypass group, including those patients with poor ventricular function or emergency cases with involving infarction, more than half of all postoperative deaths (4 pts.) were due to the poor preoperative myocardial situation of the patients.
Our data indicate to perform T-graft procedures in patients >70 years mainly in patients having diffusely diseased coronary arteries to avoid a mismatch between graft and target vessel. Other indications for a T-graft procedure are insufficient or not available venous bypass material or patients having a severely calcified ascending aorta to avoid an additional clamping of the aorta for the proximal anastomoses.
The extended preparation in combination with the enhanced preoperative morbidity of the patients in some cases leads to severe postoperative complications. That is why we recommend a well considered indication for T-graft procedures in patients over 70 years and not yet to routinely perform this operation in these patients.
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Nitsch, B., Zietak, T. & Eschenbruch, E. Erweiterte arterielle Revaskularisation (T-graft-Operation) bei über 70-Jährigen. Z Herz- Thorax- Gefäßchir 21, 45–51 (2007). https://doi.org/10.1007/s00398-007-0574-4
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DOI: https://doi.org/10.1007/s00398-007-0574-4